Post Primary School Form – Completed By Parent/Guardian


    Please fill in all fields marked with an *

    * Childs Name:
    * Childs Date of Birth:
    * Address:
    * Parent(s) or Guardian(s) Name:
    * Telephone Number(s):
    * Parent/Guardian Email Address:
    * School:
    * Year:
    * Course(LC,LCA, PLC etc.):
    * Address:
    * School Number:
    * School Email Address:
    * Name of Principal:
    Student Profile:

    * Family size:
    * Number of Boys:
    * Number of Girls:
    * Position in family:
    * Were there concerns about the student`s early development (e.g. walking, talking)?

    * Are there any medical condition/s that might be affecting academic progress? YesNo

    If there are, please give details:


    Has the student been assessed by any of the following?

    * Psychologist: YesNo
    Date Assessed:
    Outcome:

    * Physiotherapist: YesNo
    Date Assessed:
    Outcome:

    * Occupational Therapist: YesNo
    Date Assessed:
    Outcome:

    * Speech and Language Therapist: YesNo
    Date Assessed:
    Outcome:

    * Paediatrician: YesNo
    Date Assessed:
    Outcome:

    * Did the student have a hearing test? YesNo
    Outcome:

    * Did the student have a sight test? YesNo
    Outcome:

    * What are the student`s main strengths:
    * What are the student`s main interests and hobbies:
    * What are the main challenges facing the student:
    * What measures/resources could be put in place to help him/her overcome these challenges:
    Consent

    I/ We consent to a psychological evaluation of my/our son/daughter by Edward Joyce, Psychologist.

    * Name of Student:
    Name of both Parents or Legal Guardians: All persons who have legal custody of the child.

    * Father/Legal Guardian:
    * Mother/Legal Guardian:
    * Date:
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